A 78 year old lady attended casualty with complaints of low back pain and calf pain following a fall. Radiographs of lumbar spine did not reveal any bony injury. Clinically deep vein thrombosis (DVT) of the calf could not be excluded. Hence, venogram was performed that confirmed the diagnosis of below knee DVT. Patient was then discharged. Patient attended casualty 2 months later with complaints of sudden increase in back pain and difficulty in mictuirition. Radiographs of lumbar spine revealed a collapse of L1 vertebra. Routine blood tests were all normal except for raised International Normalised Ratio (INR), 3.5. Patient developed parapaeresis within three days. Coagulation status was controlled but no obvious primary source could be identified. After discussion with Neurosurgeons, urgent Computerised Tomography (CT) guided biopsy was arranged which was performed one week after presentation. Histopathological examination of the specimens revealed only fibrous tissue and blood. At 3 weeks after presentation patient started recovering rapidly though there was some amount of residual power loss in the lower limbs. Patient did not regain bladder control. A repeat CT guided biopsy at 6 weeks, again revealed only fibrous tissue.

This case is presented to discuss the rarer etiologies that can present as a metastatic spinal cord compression.

Aim: To study the management and survival outcome of patients with metastatic long bone deposits referred to a general orthopaedic unit at a district general hospital.

Methods and materials: 43 patients with pathological or impending long bone fractures were identified between 1998 and 2001. Details of primary tumor, bony metastatic involvement and management were recorded. Additional data was collected regarding prophylactic versus therapeutic treatment, oncological input, time to death and Mirel’s score, where relevant.

Results: The most common areas of long bone metastases were found to be proximal femur 29/43 (67%) and humeral shaft 11/43 (26%). Proximal femoral lesions included subcapital, intertrochanteric and subtrochanteric lesions. Operative stabilisation was carried out in 27/43 (63%), and involved intramedullary fixation (10/27; 37%), extramedullary fixation (15/27; 56%), and arthroplasty (2/27; 7%). Of the initial 43 patients, 14 (33%) presented with impending fractures, with Mirel’s scores ranging from 7 to 11 (average 9).

The duration of pre-existing pain in the in the fracture group varied from 3 days to 6 months (average 55 days). None of these patients received oncological input during this time period. Of these 15 patients, 12 subsequently required surgery.

Patient survival times in the operated group averaged 3 months (2 days to 9 months) – with the exception of one patient who survived for 36 months. This compared equally with survival times for the unoperated group.

Only 2/43 patients received preoperative oncology input. In the postoperative group (27 patients), 16 (59%) received radiotherapy. Of the remaining 11 patients, 9 (33%) did not receive radiotherapy due to significant postoperative complications and died within 8 weeks.

Discussion: The main aims of surgery in patients with metastatic bony disease are pain relief, and preservation of stability and function. In view of the low life expectancy, preoperative oncology input is important in determining patient longevity and in deciding if surgery is beneficial. All patients should be considered for postoperative radiotherapy once the wound has healed. This multi disciplinary approach can be difficult to achieve in the setting of a district general hospital where oncology services are limited.

A fifty year old lady with history of rheumatoid arthritis (RA) for 24 years and COPD for 10 years was admitted for investigation of persistent chest infection and for the control of RA flare-up. She was on Sulphasalazine, NSAIDs and had completed a course of gold injections and on admission started on methotrexate, folic acid, Calcium, bisphosphonates and alendronate. Urinanalysis was positive for Bence Jones’ Proteins (BJP). Four days after admission patient developed spontaneous pain in the right thigh with inability to move the right leg. Radiographs showed a supracondylar femoral fracture through a lytic lesion, which was stabilised with a Distal femoral nail. At surgery bone quality of right femur was found to be very poor. Radiographs of the left femur showed a lytic lesion in the subtrochanteric region, which was stabilised prophylactically with a Proximal Femoral Nail. Histopathological examination of the marrow reamings from right femur showed no neoplastic changes and from left femur showed occasional plasma cells. 24 hour urinanalysis showed BJP of 0.22g/hour and protein electrophoresis showed monoclonal antibodies. Bone marrow biopsy was performed which showed only reactive cells. A week later 24 hour urine BJP was down to 0.13g/hour. At three weeks, symptoms of RA were under control and the protein electrophoresis showed no monoclonal banding. Chest infection resolved with appropriate antibiotics. Computerised Tomography of chest showed bronchiectasis with no evidence of neoplasm.

Discussion: In acute stages of RA there is an increase in antibodies production that may present as positive for monoclonal antibodies on electrophoresis and by the same reason urine may be positive for BJP. The spontaneous fracture in this case could be due to severe reactive osteoporosis confounding the clinical picture of active RA. Without clear evidence of myeloma or plasmacytoma, instituting chemotherapy may lead to further complications in patients with RA.

A 52 year old male presented with a pathological subtrochanteric femoral fracture secondary to multiple myeloma. While stabilising the fracture with a Long Proximal Femoral Nail (PFN) distal femur fracture occurred, while introducing the distal locking screw, which was fixed with two cables. Partial weight bearing was allowed for the first six weeks.

Three months after surgery the distal static locking screw broke. Eighteen months post surgery patient developed sudden spontaneous right hip pain and was treated with further chemotherapy and radiotherapy. Radiographs showed the fracture had not healed but there was no evidence of implant failure. Two years later patient presented with sudden increase in right hip pain with inability to walk. Radiographs showed that the nail had broken at the proximal hip screw hole.

At revision surgery, with difficulty the broken distal locking screws were removed and the broken nail was removed by pushing it from below through the knee. The non union was stabilised with another long PFN. At four months post revision surgery there were radiological signs of bone healing and patient had no symptoms.

Discussion: Reconstruction nails such as long PFN are bio mechanically suited for proximal femoral fractures and metastases. Bone cement augmentation has been reported to provide additional support in metastases. Dynamisation of the fracture leads to fracture impaction and promotes fracture healing. In this case implant failure was probably due to non union and fatigue failure of the implant. In spite of ‘spontaneous’ dynamisation (broken static distal screw), union did not occur initially.

This is the first reported incidence of failure of long PFN in a pathological femoral fracture stabilisation.

Between April 1999 and December 2001 forty-one patients (forty-five femora) with metastatic lesions in the proximal femur involving intertrochanteric and subtrochanteric regions were stabilised with Proximal Femoral Nail (PFN). Thirty-eight patients (forty-two femora) were followed up for a mean period of 20 months (range 3 weeks to 35 months). There was an overall increase in mobility in 60% of the patients and the rest remained the same. Mean Preoperative Visual analog scale rating for thigh pain was 8.1 versus 3.4 for postoperative score (p< 0.01). There were no complications with respect to PFN. There were three post operative complications – chest infection, superficial wound dehiscence and pulmonary embolism. All these complications resolved without any further deterioration. Since these lesions do not usually heal well a cephalomedullary device is ideal to withstand long-term cyclic loading. Minimal operative trauma, mechanical stability, early mobilisation, pain relief and short hospital stay are the advantages of PFN in stabilising impending fractures of the proximal femur.

Aim: To report the experience with the new device, the Long Proximal Femoral Nail (Long PFN) in patients with impending pathological femoral fractures to identify the advantages and complications associated with its usage. This is the þrst in the series on the use of Long PFN for patients with femoral metastases. Methods: Between April 2000 and September 2001, twenty-þve consecutive patients with femoral pathological lesions were prophylactically stabilised using Long PFN. The nailings were performed using a percutaneous closed technique. Lateral femoral Line (LFL) technique was used for location of the entry point and easy insertion for the nail. Only the proximal one þfth of the femur was reamed to accommodate the 17 mm diameter of the proximal part of the nail. Results: We had technical problems in three patients. The overall mobility of the patients improved in twenty patients and the mobility remained the same as preoperative level in þve patients. Good to excellent pain relief achieved in eighteen patients. The pain relief was fair in þve patients and poor in two patients. We had no mechanical failure of the implant in our series. Conclusion: Long PFN, a modiþed reconstruction nail, which can be inserted percutaneously and has an easy operation technique. Our early experience with Long PFN in the management of impending femoral fractures has been favourable.

Hips and knees are commonly replaced joints for which several types of prostheses are available. As newer versions of the prostheses are brought in, older versions are phased out. When revision is for an isolated component failure as in, wear of acetabular cup, isolated revision of the acetabular cup is an accepted procedure. If the plan is to revise just the isolated component then that particular model of prosthesis should still be available.

In an attempt to check the availability of revision components for joint replacements we wrote to ten prostheses manufacturers enquiring the availability of prosthetic components. To have a comparison, we also wrote to eighteen leading car manufacturers enquiring about the duration and any guarantees on the availability of car spare parts.

From our survey we found that the availability of the revision implants was satisfactory in that all the prostheses manufacturers were eager to provide as much assistance as possible. The draw back is that there are no regulations to ensure the availability of these prosthetic components for any length of time after discontinuation of a particular model.

The car manufacturers are not under any obligation to provide spare parts for discontinued models. The argument put forward by some manufacturers for providing spare parts up to ten years from discontinuing the model was that “it would not reflect well on the company” if it were for any lesser length of time.

Conclusion: At present though there are no regulations on the time period of availability of total joint prosthetic components. The manufacturers have taken it upon themselves to provide the prosthetic components whenever a specific request is made. If the manufacturers say they can not provide the implants there is nothing in the governmental regulations that provide for recourse.

The composition and morphology of the glenoid are integral to the support of a glenoid component in total shoulder arthroplasty (TSA). This study was performed to identify the morphology of glenoid cavity in pre and post replacements in a cadaveric model.

Eleven normal cadaveric shoulders (Right – 5, Left – 6) were dissected down to the bone such that the glenoid labrum was left intact. Computerised Tomography (CT) scanning at 0.5 mm thickness was performed on each of the specimens in a standardised fashion to evaluate the morphology of the glenoid and glenoid medullary cavity. CT scanning was repeated after a mixture of cemented pegged and keeled glenoid components were inserted into all the specimens using standard instrumentation.

Five reproducible lengths (Body width), Posterior wall length, Anterior Wall length. Glenoid body length and corrected body width) and the retroversion angle of the glenoid were identified on the CT scans. These measurements were taken at the 25th, 50th and 75th percentiles of the height of each glenoid both pre and post replacements. Further post glenoid replacement CT scans were analysed for cement-fill of the glenoid cavity and cortical encroachment of the prosthesis.

There was significant correlation of all the measurements including the retroversion angle between the pre and post glenoid replacements at all levels. All but one pegged prosthesis had insufficient cement mantle or critical penetration or abutment at one of the pegs at least. Most often the penetration or cortical abutment was along the posterior wall. All keeled prosthesis had a sufficient cement mantle all around.

The designs of the glenoid prosthesis were satisfactory with some respects like radius of curvature, size and to a certain degree the shape. The margin of error for insertion of the pegged prosthesis was very narrow. Design changes are required in the glenoid component for better bony fixation.